Adenomyosis occurs when the tissue that normally lines the uterus (the endometrium) grows into the uterine muscle (myometrium), and while it’s often compared to endometriosis which is another disorder of endometrial tissue, the two conditions are different. The exact cause of adenomyosis is unknown but there is a connection to estrogen since the disease resolves after menopause.
Endometriosis involves endometrium-like tissue outside the uterus (sometimes on ovaries or fallopian tubes), whereas adenomyosis is confined to the uterine wall. Like endometriosis, the misplaced tissue in adenomyosis responds to menstrual hormones, thickening and breaking down and causing inflammation and pain because the tissue cannot shed normally. While many people are asymptomatic, others experience symptoms including heavy, painful periods, irregular bleeding, premenstrual pelvic pain, painful intercourse, and painful urination or bowel movements, and the heavy bleeding can lead to iron-deficiency anemia.
Adenomyosis most commonly appears in people in their 40s. Women at risk of adenomyosis include those who have had previous uterine surgery including a C-Section, fibroid removal or a dilatation and curettage, had childbirth or middle age women.
Common signs and symptoms of adenomyosis include an enlarged uterus, painful periods, heavy and irregular bleeding, painful sex and infertility. It’s estimated that 1/3 of women don’t have any symptoms from adenomyosis while 2/3 do.
It can coexist with conditions like endometriosis and fibroids, and while the exact cause is unknown, hormone dependence, genetics, immune factors, and abnormal healing after uterine surgery are suspected contributors.
Diagnosis is challenging and frequently delayed because symptoms overlap with other disorders (endometriosis, IBS, PID, perimenopause) and diagnostic criteria aren’t standardized; transvaginal ultrasound identifies nearly half of cases and MRI can help when ultrasound is inconclusive.
Diagnosis of adenomyosis is based on the symptoms a woman is experiencing and findings done on a pelvic Ultrasound or Magnetic resonance imaging (MRI). Since 1/3 of women don’t experience any symptoms adenomyosis is often underdiagnosed. Painful periods with heavy and irregular bleeding can be seen in a number of other medical conditions so putting all the pieces together can be challenging for health care providers. Ordering a pelvic ultrasound can help make the diagnosis easier since there are landmark findings on this cost friendly imaging study.
Many health experts still have disagreements on defining and classifying the imaging and pathology caused by adenomyosis.
Treatment focuses on symptom relief rather than cure and ranges from over-the-counter pain relievers and hormonal options (progestin-only pills or levonorgestrel IUDs to thin the lining) to uterine artery embolization for symptom control, with hysterectomy as a definitive option for those who no longer desire fertility.
The best treatment options for someone with adenomyosis who still wants to conceive will depend on the symptoms she is experiencing.
Nonsteroidal anti-inflammatory medication will be helpful for menstrual cramps and pelvic pain.
The birth control pill and progesterone IUD will control heavy and irregular periods and menstrual cramps.
If you have persistent symptoms of painful periods, heavy and irregular bleeding, painful sex or infertility and don’t feel satisfied with your healthcare experience, be your best health care advocate and bring up the potential diagnosis of adenomyosis.
The most effective treatment for endometriosis is ultimately how well the patient responds. Many do well using hormonal (birth control pills or GnRH agonists) therapy with pain relievers, while other need a combination of medical therapy and surgery (excision/removal of endometriosis) for optimal treatment of debilitating endometriosis.
Endometriosis is a chronic and long-term disease. The goal in the treatment of endometriosis is to manage the disruptive symptoms, and progression, caused by this challenging disease.
Factors that affect endometriosis treatment include the severity and disruption of symptoms, fertility status, and patients age that guide treatment recommendations.
Typically pain medications are used to manage disruptive symptoms caused by endometriosis. Pain medications are not used to treat endometriosis, rather the debilitating symptoms caused by the disease, in combination with hormonal therapy or surgery.
Depending on the severity of symptoms caused by endometriosis, hormonal therapy is often the first line of treatment options for patients. Hormonal therapy can slow the progression and growth of endometrial implants by decreasing the levels of estrogen in the body, but it is not a permanent treatment for endometriosis. If hormonal therapy is discontinued, the growth and symptoms of endometriosis can return.
When conservative medical management including hormonal therapy and pain management fails, and symptoms become more debilitating, surgery excision of endometriosis is the next best option.
Understanding that these are two different disruptive gynecologic diseases affecting women is the beginning in finding effective treatment options.
